TEVAR DOES NOT ALTER THE NATURAL HISTORY OF TRAUMATIC AORTIC DISRUPTION

BACKGROUND:
TEVAR is an accepted treatment option for traumatic aortic disruption (TAD) despite little data on long-term outcome. We hypothesized that early placement of TEVAR in patients with TAD would reduce deaths from aortic rupture in patients who arrive alive at the hospital.
METHODS:
We reviewed the medical records of 112 patients with TAD treated at a Level I Trauma Center over a ten year period. Medical Examiner autopsy reports were reviewed on all patients who died in the hospital to determine cause of death.
RESULTS:
30 patients (26%) were pronounced dead on arrival. Of the 82 alive patients, 33 (40%) died in the hospital. The mean injury severity score for patients who died was 43 + 12, compared to 34 + 12 for surviving patients (P = .001). In-hospital deaths were caused by aortic rupture in 12 patients (15%), other traumatic injuries in 19 patients (23%), and multisystem organ failure following aortic repair in two patients (2%). All 12 deaths from aortic rupture occurred within 4 hours of injury: 5 died in the emergency room or CT scanner, and 7 died in the operating room. Aortic injury was recognized in only two of the 7 patients who died intraoperatively and therefore represent the only patients who might have been salvaged with immediate TEVAR.
59 patients survived beyond 4 hours with contained TAD. 8 (14%) of these patients died of associated injuries. 19 (32%) underwent aortic repair (17 open, 2 TEVAR) within 24 hours due to severe aortic disruption or minimal associated injuries; two died of postoperative complications. 22 (37%) had delayed repairs (13 open, 9 TEVAR) because of infectious complications or the need to treat other organ system injuries; all survived to discharge. The mean length of hospital stay after TEVAR was 30 + 30 days, which was not different compared to 33 + 27 days after open repair. Operative complications occurred in 8 of 30 patients after open repair and in one of 11 after TEVAR (P=NS). Regardless of repair type, 7 (37%) of the 19 patients in this series who underwent repair within 24 hours developed operative complications, compared to two (9%) of the 22 who underwent delayed repair (P =.08). Ten (17%) surviving patients with minimal TAD were treated with beta blockade and observation; 3 of these have stable aortic injuries and 7 were lost to follow-up.
CONCLUSIONS:
Most patients with TAD who arrive alive at the hospital do not experience aortic rupture. Rupture appears to occur within the first 4 hours of admission, before the injury can be recognized in time for salvage with immediate TEVAR. No patient in this series who survived beyond 4 hours died of aortic rupture. Mortality was related to the extent of associated injuries and was not influenced by the type or timing of repair.